AMHC Integrated Service Approach

1. AMHC Integrated Service Approach February 9, 2010

2. AMHC Locations

3. AMHC & Integration: 36 Year History • Strategic priority for AMHC • Vision aligned with Four Quadrant, Strosahl and Care Model • Dedicated to improving health and wellness through a biopsychosocial approach • Implementing brief treatment and Stanford chronic disease lifestyle management model developed by • Guided by written, customized integration protocols for defined diseases and supported by expert training resources • Grounded in principles of providing immediate access to most appropriate, highest quality, affordable service • Informed by decades of experience working in Aroostook County, in Maine, nationally through MHCA, and internationally through IIMHL

4. IOM Influence • Grounded in the Institute of Medicine’s (IOM) Crossing the Quality Chasm aims: • patient-centered • safe • timely • efficient • effective • equitable

5. Service Models • Four Quadrant Clinical Integration Model • Chronic Care Model • Strosahl Primary Behavioral Health Care Model

6. Four Quadrant Clinical Integration ModelPresentation by Service Population and Setting

7. Care Model Health System Community Resources and Policies Health Care Organization Registry PHQ-9 Self-Mgmt Tools ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Psych consult Care Mgmt Prepared, Proactive Practice Team Productive Interactions Informed, Activated Patient Improved Outcomes / ICIC

8. Strosahl Primary Behavioral Health Model • Goal is to increase effectiveness of primary care providers in addressing behavioral health needs of patients. • Focus on managing psychosocial aspects of disease by addressing lifestyle and health-risk issues through brief consultative interventions and temporary co-management of behavioral health conditions.

9. Self-Care

10. Self-care Objectives • Patient at the center and in control of his health. • Uses a broad variety of techniques to attain and achieve optimal health. • This is a fundamental shift in the paradigm of health services currently focused on treating disease and expects practitioners to work with a patient to inform and support his ability to guide his own self-care.

11. Advantages • Improve access to behavioral and physical health services • Apply evidence based practices to improve client outcomes • Improve provider communication and coordination of care • Foster a multi-disciplinary team approach to treating substance abuse with a co-occurring chronic health issues (cancer, cardiovascular, COPD, depression, diabetes)

12. Advancing Approach to Practice • Embedding primary care family practice physician into AMHC’s service site to provide outpatient and medication management services • Primary goals: • Encourage self-care • Improve type and quality of services • Meet unmet needs • Increase cost efficiency • Address workforce issues and offer professional advancement • Improve primary care physician ability to treat patients with chronic mental illness

13. Key Activity Milestones • Administrators and clinical staff were oriented to the principles of the Four Quadrant Model and how it interfaces and complements the Planned (Chronic) Care Model. • Written, customized integration protocols for depression, anxiety, substance abuse, sexual assault, were developed • Assessment tools for depression, PQ-9, and substance abuse, the CAGE, were implemented and are used at the sites. • One blended record at the primary care site. • Periodic provider team meetings held to address care coordination and collaboration issues • Scheduling, staff credentialing and billing issues were improved Successfully secured DHHS reconsideration and approval for FQHC’s to bill MaineCare and be reimbursed for services provided by LMSW-cc credentialed clinicians. • Clinician assignments to support the integration efforts were maintained, with 90% of initial placements sustained throughout the life of the project. • Six Pines physicians have staffed AMHC’s opioid replacement therapy clinic since July 2006. • AMHC implemented an account management approach to working with the primary care practices to ensure immediate responsiveness to addressing clinical approach, staff availability, credentialing, scheduling, and billing issues.

14. Why integrate services? • International, national and state level movement to integration of services • Federal Level Public Support • HRSA and SAMHSA and their counterparts in other countries through the International Initiative for Mental Health Leadership (IIMHL) • Private National Organizations • Institute of Medicine (IOM) • National Council for Community Behavioral Healthcare (NCCBH) • Mental Health Corporations of America (MHCA) and its counterpart State Level Public support • Department of Health and Human Services (DHHS) • Private Maine State Organizations • Maine Health Access Foundation (MeHAF) • Quality Counts (QC) • Primary Care Association (MePAC) • Association of Mental Health Services (MAMHS) • Association of Substance of Abuse Programs (MASAP)

15. Potential and Sought After Rewards • Improved Health Outcomes • Healthier Patients • Increased Patient Satisfaction • MeHAF focus groups found • MH & SA patients reported having a higher degree of integrated care • PH patients express a sense of loss when case management services offered by specialty providers were stopped and they returned to “regular care” • Improved staff satisfaction • Working Conditions • Perceived effectiveness in delivering quality services • Coordination of services across multi-disciplinary professional

16. Potential and Sought After Rewards • Improved Organizational Performance • Achieving Service Mission and Business Objectives • Service Effectiveness • More comprehensive array of service responses aligned with true service needs • Service Efficiency • Increased capacity and productivity achieved through appropriate utilization of multi-disciplinary staff resources • Improved Financial Performance • Reduced cost of providing services when responses are aligned with true service needs • Improved revenues generation resulting from increased productivity across multi-disciplinary staff.

17. How integrated are we? • 5 Levels of Integration • I. Minimal collaboration • II. Basic collaboration from a distance • III. Basic on site collaboration • IV. Close collaboration that is partly integrated • V. Fully integrated System

18. Project Mission • “To provide comprehensive, patient centered care that offers concurrent prevention and management of multiple physical and behavioral healthcare service needs of a patient in relationship to his or her family, life events, and environment.”

19. Project Activities • 1. Confirm: • Medical Director’s commitment to participate in and help guide the process. • Behavioral and Physical Healthcare Provider willingness to • Improve integrated services • Participate in regularly scheduled multi-disciplinary staff meetings • 2. Provide Refresher and Ongoing Education • Integration Models and/or Evidence Based Practices • Strategies to reduce barriers and advance integrated service practice • 3.Commit to Including Patients in the Project to Help: • Increase awareness, encourage participation, and reduce stigma.

20. Project Activities • 4. Improve Delivery of Substance abuse and Co-occurring Disorder Services • 5. Implement Care Coordination and Patient Self-management Services • 6. Identify, Implement and Monitor Measurable Indicators to Support the Reporting of Achieved Outcomes.

21. Integration Barriers in Maine • Culture and Practice Patterns • Selecting integration model(s) based on practice context • 15 minute visit vs. 50 minute therapy session • Education of providers is silo’d and there is no or limited understanding across disciplines.

22. Integration Barriers in Maine • Stigma and lack of awareness • Stigma associated with some behavioral and physical health service needs is a barrier to seeking and providing service. • Patient and provider lack awareness about integrated care and the advantages. • Patients generally lack an understanding about how they may be able to self-manage care and advocate for integrated services.

23. Integration Barriers in Maine • Reimbursement: No reimbursement for integrative (e.g., collaborative care and team approaches), care coordination, and preventative services.

24. Next Steps